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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600907
Report Date: 02/22/2024
Date Signed: 02/22/2024 05:22:12 PM


Document Has Been Signed on 02/22/2024 05:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SILVERGATE FALLBROOK RETIREMENT RESIDENCEFACILITY NUMBER:
374600907
ADMINISTRATOR:PATRICIA A MARTINEZFACILITY TYPE:
740
ADDRESS:420 ELBROOK DRIVETELEPHONE:
(760) 728-8880
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:145CENSUS: 95DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Patricia Martinez, Exectuive Director TIME COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required/annual visit. LPA was greeted and granted entry by receptionist Josefina Cornejo. The Executive Director Patricia Martinez then greeted LPA, where LPA the purpose of the visit. LPA conducted a review of the facility personnel roster and observed for all staff that LPA came in contact with to have obtained proper fingerprint clearance, and to be associated to the facility. The facility is licensed licensed to serve one hundred forty five (145) elderly residents, that may have dementia; all of whom may be non-ambulatory, twelve (12) that may be bedridden. The facility has an approved hospice waiver for sixteen (16) residents. There are currently seven (7) residents on hospice.

LPA conducted a tour of the interior and exterior of the facility. LPA observed the following:
The facility is currently painting/touching up the exterior of the facility. Per Executive Director Patricia Martinez there is also current roof repairs being completed as a result of the recent rain. The facility was observed to be clean, clutter and odor free. Most of the residents were observed to enjoy socializing with one another listening to music during happy hour.

The facility has multiple smoke and carbon monoxide detectors strategically placed throughout the facility. Detectors in each building were randomly checked and were observed to be operable. There are several fire extinguishers throughout the community that were observed to be fully charged. The facility is conducted emergency disaster drills on a quarterly basis, the last drill conducted was on 1/25/24. The next upcoming drill is scheduled for March 2024. The facility has a functional signal system that operates from each resident bedroom. As each resident bedroom has pull cords, they were randomly checked and observed to be operable. Sharps, disinfectants, cleaning solutions, and poisons are locked and were observed inaccessible to residents. There are known no guns or ammunition on the premises.

The hot water temperature was checked randomly in resident bathrooms in all three (3) buildings. The hot temperature was found to be within regulatory limits ranging from 106.6-114.4 degrees F.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SILVERGATE FALLBROOK RETIREMENT RESIDENCE
FACILITY NUMBER: 374600907
VISIT DATE: 02/22/2024
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A tour was conducted of the kitchen, LPA observed dining staff prepping for dinner, and the surfaces used to prepare the food was observed to be clean. The facility was observed to have a 7 day supply of non-perishable and a 2 day supply of perishable food items. The refrigerators were clean, organized and all food was properly stored.

The medications were observed to be in a locked place that is inaccessible to residents. The facility requires all medical staff to have a current First Aid/CPR training. Resident files were reviewed and found to have the required documents (physician's report/physical, appraisal/needs and services plan and admission agreement).

Mrs. Patricia Martinez will provide a copy of the facility's current liability insurance to the regional office for the facility file.

Based on today's inspection no deficiencies were observed. An exit interview was conducted and a copy of this report was provided to Patricia Martinez, Executive Director.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
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